PhilSPEN Online Journal of Parenteral and Enteral Nutrition

(Article 135 | POJ_0127)

Original Clinical Investigation

The Global Leadership in Malnutrition (GLIM) - from the Philippines perspective

Abstract | Introduction | Methodology | Results | Discussion | Conclusion | References | Back to Total Name and Codes page2

Submitted: | Posted:

Authors:

From the GLIM project coordinators (philspen_sec@yahoo.com)

Institutions where research was conducted

  1. Clinical Nutrition Sevice, St. Luke’s Medical Center, E. Rodriguez Avenue, Quezon City, Metro-Manila, Philippines
  2. Adult Medical Nutrition Fellowship Program, The Medical City Ortigas Avenue, Pasig City, Metro-Manila, Philippines

 

ABSTRACT: | Back

Background:

This initiative is aimed at building a local consensus around core diagnostic criteria for malnutrition in adults in clinical settings

Objective:

On 2020 the Global Leadership Initiative on Malnutrition (GLIM) was called by the local PBCN (Philippine Board of Clinical Nutrition) and appointed a committee to work on and finish this nutritional assessment profile.

Results:

  1. A two-step approach for the malnutrition diagnosis was selected.
  2. First screening to identify “at risk” status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition.
  3. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment.
  4. The top five ranked criteria included three phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and two etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden).
  5. To diagnose malnutrition at least one phenotypic criterion and one etiologic criterion should be present.
  6. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories.

Conclusion:

  1. A consensus scheme for diagnosing malnutrition in adults in clinical settings is conceptualized.
  2. The diagnostic construct should be re-considered every 3-5 years.

KEYWORDS: Global Initiatives in Leadership on Malnutrition

 

INTRODUCTION | Back

Malnutrition due to disease, poverty, hunger, war, and natural catastrophe is a fate suffered by greater than 1 billion of the world’s population. However, with improvements in agriculture, education, public health, healthcare, and living standards, nutrition disorders and related conditions now encompass the full scope of undernutrition, micronutrient abnormalities, obesity, cachexia, sarcopenia, and frailty (1, 2).

Malnutrition, i.e. undernutrition, may be caused by compromised intake or assimilation of nutrients but there is growing appreciation that malnutrition may also be caused by disease-associated inflammatory or other mechanisms. The malnutrition that is associated with disease or injury invariably consists of a combination of reduced food intake or assimilation and varying degrees of acute or chronic inflammation, leading to altered body composition and diminished biological function (1-3).

Inflammation contributes to malnutrition through associated anorexia and decreased food intake as well as altered metabolism with elevation of resting energy expenditure and increased muscle catabolism. Altered body composition manifests as a decrease in any marker of muscle mass (fat-free mass, muscle mass index or body cell mass). Thus malnutrition is associated with adverse functional and clinical outcomes.

Although malnutrition is a global concern, there has been a fundamental lack of consensus on diagnostic criteria. No single existing approach has secured broad global acceptance (1, 4-8).  Our evolving understanding of the contributions of disease/inflammation may render some concepts of malnutrition in the current International Classifications of Diseases (ICD-10) (http://www.who.int/classifications/icd/en/) inconsistent with approaches or nomenclature that are currently used in clinical practice and research. Thus, there is an urgent need to establish a global consensus to be used in clinical care settings for adults.

In order to respond to the needs of the clinical nutrition and medical communities the Global Leadership Initiative on Malnutrition (GLIM) was convened in January 2016. GLIM has engaged several of the clinical nutrition societies with global reach to focus on standardizing the clinical practice of malnutrition diagnosis. We also sought to clarify overlaps with related disease classifications including cachexia.

The purpose of this specific initiative is to reach global consensus on the identification and endorsement of criteria for the diagnosis of malnutrition


METHODOLOGY | Back

The consensus procedure

  • It was recognized that there was considerable consensus among stakeholders around many malnutrition diagnosis issues
  • There was strong commitment for reaching broader global consensus in defining and characterizing malnutrition
  • A core leadership committee with representatives of several of the global clinical nutrition societies; ASPEN (www.nutritioncare.org), ESPEN (www.espen.org), FELANPE (www.felanpeweb.org) and PENSA (www.pensa-online.org) was constituted to form GLIM. The core GLIM leadership committee then created a larger supporting working group comprised of invited members that brought additional global diversity and expertise to the consensus effort.
  • The first full meeting of the GLIM extended working group was held September 19, 2016 at the ESPEN Congress (10). Highlighted objectives included consensus development of evidence-based criteria suitable to diverse clinical settings, global dissemination of consensus criteria, and the priority to seek adoption by leading diagnosis classification and coding entities across the globe.
  • It was also agreed that the desired approach to malnutrition diagnosis should be simple and include clinically relevant diagnostic criteria that will be appropriate for application by all healthcare professionals using methods that are widely available.
  • The intent was also to promote global use of consensus criteria that can be readily used with other approaches and additional criteria of regional preference.

Results Consensus was gradually achieved over the course of the three GLIM meetings held February 20, 2017 at the ASPEN Conference (11), September 11, 2017 at the ESPEN Congress, and January 25, 2018 at the ASPEN Conference. Meanwhile, discussions were also held with the leadership of The Society of Sarcopenia, Cachexia and Wasting Disorders (SCWD).

A two-step model for risk screening and diagnosis assessment

a) The first step in the evaluation of nutritional status is malnutrition risk screening to identify “at risk” status by the use of any validated screening tool (12-14); some of these tools are noted in Table 1 and the Appendix.

b) This is followed by the second step of assessment for diagnosis and severity grading as described below.

Criteria selected for malnutrition diagnosis

A comprehensive survey of existing approaches used in screening and assessment of malnutrition was conducted to identify criteria worthy of consideration (Table 1 and the Appendix).

It was recognized that these approaches incorporate multiple common criteria. For example the presence of weight loss and disease burden or inflammation is common to most of them as is reduced food intake (Table 1).

Potential consensus criteria from existing approaches as well as additional criteria suggested by participants were subject to further consideration.

In order to establish consensus and endorsement of a minimum set of diagnostic criteria by the core leadership committee and the supporting working group a formal ballot was administered whereby participants ranked proposed diagnosis criteria. The top 5 ranked criteria by an overwhelming majority of GLIM participants were as follows:

  • Non-volitional weight loss
  • Low body mass index (BMI)
  • Reduced muscle mass
  • Reduced food intake or assimilation
  • Disease burden/inflammation

Non-volitional weight loss

There was strong GLIM consensus for the inclusion of non-volitional weight loss as a phenotypic criterion. Validity is well established and there is a robust literature on which threshold selection could be based (Appendix).

There must be priority to obtain repeated weight measures over time to identify trajectories of decline, maintenance, and improvement. GLIM participants felt that it is especially important to recognize the pace of weight loss early in the course of disease or injury and to highlight that many patients will have lost appreciable weight prior to presenting to the healthcare.

Low BMI

There is substantial regional variation in the use of low BMI as a phenotypic criterion for malnutrition diagnosis. North American GLIM representatives indicated that BMI is seldom used as a clinical malnutrition marker in those regions. The experience from the current American population is that people are often overweight or obese and would need to lose substantial weight before low BMI designation would occur.

Since other regions of the world currently make extensive use of BMI as a criterion for recognition of malnutrition, the GLIM consensus includes low BMI. Further research is however needed to secure consensus reference BMI data for Asian populations in clinical settings.

Reduced muscle mass

Reduced muscle mass is a phenotypic criterion with strong evidence to support its inclusion in the GLIM consensus criteria. However, there is not consensus regarding how best to measure and define reduced muscle mass, particularly in clinical settings. Therefore, GLIM recommends measurement by dual-energy absorptiometry (DEXA) or other validated body composition measures such as bioelectrical impedance (BIA), ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI), but these methods are still not available in most settings for nutritional assessment throughout the globe. Physical examination or anthropometric measures of calf or arm muscle circumference are therefore included as alternative measures.

Recommendations are likely to evolve as portable and less costly body composition technologies are developed and become widely available.

For the purpose of recommended cut-off values for muscle mass reductions, GLIM refers to recommendations from the European Working Group on Sarcopenia in Older People (EWGSOP) (15) and from The Foundation of National Institute of Health (FNIH) initiative (16), and the Asian Working Group on Sarcopenia (AWGS) (17). The formal assessment form for GLIM (on Filipino patients) including the three forms of human muscle mass dynamometer are included here.

Reference standards for muscle mass may warrant adjustment for race and sex. Additional research is warranted to establish general reference standards as well as for some specific populations, e.g. in Asia. Examples of recommended thresholds are found in Table 2. Assessment of muscle function using grip strength or other validated procedures is recommended as a supportive measure in the GLIM consensus (Figure 1 and Table 3). Decline in muscle strength generally exceeds changes in muscle size (18).

However, irrespective of etiology, appreciable loss of muscle mass is generally accompanied by reduced muscle function. In situations where muscle mass cannot be readily assessed then muscle strength, e.g. hand grip strength, is an appropriate supporting proxy.

Reduced food intake or assimilation

Reduced food intake is a well-established etiologic criterion for malnutrition that has strong validity. It can have multiple causes including poor oral health, medication side effects, depression, dysphagia, gastrointestinal complaints, anorexia and inadequate nutrition support. Thresholds for relevant impairment of food intake are widely reported (Appendix) and GLIM participants sought to empirically provide a practical synthesis.

Reduced assimilation of food/nutrients is associated with malabsorptive disorders like short bowel syndrome, pancreatic insufficiency and after bariatric surgery. It is also associated with gastrointestinal symptoms like dysphagia, nausea, vomiting, diarrhea, constipation, and abdominal pain. These symptoms have been incorporated as supportive indicators into this GLIM consensus criterion to help to identify poor food intake or malabsorption.

Disease burden/inflammation

GLIM members recognized that disease burden/inflammation has become a widely accepted etiologic criterion in existing screening and assessment tools (Table 1). Clinical diagnosis provides a simple approach to recognition of inflammation (1, 2, 19). For example major infections, burns, trauma, and closed head injury are associated with acute inflammation of a severe degree.

Indicators of inflammation may include fever, negative nitrogen balance, and elevated resting energy expenditure. Most chronic organ diseases, like congestive heart failure, chronic obstructive pulmonary disease, rheumatoid arthritis, chronic kidney or liver disease and cancer, are associated with chronic or recurrent inflammation of a mild to moderate degree. While severe inflammation is generally easy to discern, clinical judgement is often required to recognize that of lesser degree. Supportive proxy measures of inflammation can include laboratory indicators like serum C-reactive protein (CRP), albumin, or pre-albumin.

Approach to using combined phenotypic and etiologic criteria for malnutrition diagnosis

Weight loss, reduced BMI, and reduced muscle mass were categorized as phenotypic criteria, and reduced food intake/malabsorption and disease burden/inflammation as etiologic criteria (Figure 1).

For the diagnosis of malnutrition, GLIM recommends that the combination of at least one phenotypic criterion and one etiologic criterion is required (Figure 1).

The selection of threshold values for the consensus diagnostic criteria was guided by review of existing approaches used in screening and assessment as was the selection of threshold values for severity grading described below (see Appendix). The selected threshold values for diagnosis of malnutrition are shown in Figure 1.

Severity grading of malnutrition

It is clinically useful to categorize the severity of malnutrition into Stage 1 (moderate) and Stage 2 (severe) depending on the degree of aberration from established thresholds. 

The GLIM recommended grading hierarchy is shown in Table 3.

Etiology-based diagnosis classification

An etiology-based diagnosis classification is endorsed by GLIM consistent with those suggested previously by the International Consensus Guideline Committee (1), the AND/ASPEN Guidelines (7), and the ESPEN Guidelines (2).

The classification includes malnutrition related to chronic disease with inflammation, malnutrition related to chronic disease with minimal or no perceived inflammation, malnutrition related to acute disease or injury with severe inflammation, and malnutrition related to starvation including hunger/food shortage associated with socioeconomic or environmental factors (Table 4).

RESULTS | Back

Nutritional Assessment Form

glimform1

  • c = Acute disease/injury-related with severe inflammation, e.g. major infection, burns, trauma or closed head injury.
  • d = Chronic disease with chronic or recurrent mild to moderate inflammation; e.g. malignant disease, chronic obstructive pulmonary disease, congestive heart failure or chronic renal disease.
  • e = Acute disease/injury-related. Severe inflammation is likely to be associated with major infection, burns, trauma or closed head injury. Other acute disease/injury-related conditions are likely to be associated with mild to moderate inflammation.
  • f = Chronic disease-related. Severe inflammation is not generally associated with chronic disease conditions. Chronic or recurrent mild to moderate inflammation is likely to be associated with malignant disease, chronic obstructive pulmonary disease, congestive heart failure, chronic renal disease or any disease with chronic or recurrent Inflammation.

glimform2

Hand Grip Data from normal, average, and sick patients data

  Phenotypic Criteria Etiologic Criteria

 

Weight Loss (%)
Low Body Mass (a)
Reduced Muscle Mass (b)
Reduced food intake or assimilation
Disease burden/ Inflammation
Stage 1/ Moderate Malnutrition (Requires 1 phenotypic and 1 etiologic criterion)
5-10% within the past 6 mo or 10-20% beyond 6 mo

<20 if <70 yr, <22 if >/- 70 yr

Mild to moderate deficit (per validated assessment methods - see below)
Any reduction of intake below ER for >2 weeks (c) or Moderate malabsorption (d)
Moderate acute disease/ injury related (e) or Moderate chronic disease related (f)
Stage 2/ Severe Malnutrition (Requires 1 phenotypic and 1 etiologic criterion)
>10% within the past 6 mo or 20% beyond 6 mo
<18.5 if <70 yr, <20 if >/- 70 yr
Severe deficit (per validated assessment methods - see below)
</- 50% intake of ER for >1 week (c) or Severe malabsorption (d)
Severe acute disease/ injury related (e), or Severe chronic disease-related (f)

Figure 1. GLIM diagnostic scheme for screening, assessment and diagnosis of malnutrition.

Figure 2. Approach to Diagnosis of GLIM associated schemem for Nutritional Assessment

1. At risk for malnutrition > Use validated screening tools > Risk screening is done

2. Assessment criteria > for full assessment

3. Use the following:

a) Phenotypic criteria (just one criterion is used)

  • Non-volitional weight loss
  • Low body mass index
  • Reduced muscle mass

b) Etiologic criteria (just one criterion is used)

  • Reduced food intake or assimilation
  • Disease burden / inflammatory condtion

4. Diagnostic Assessment > Meets criteria for malnutrition diagnosis

  • Requires at least 1 Phenotypic criterion and 1 Etiologic criterion
5. Diagnosis is made

Phenotypic Criteria

Etiologic Criteria

Weight loss (%)

Low body Mass Index (kg/m2)

Reduced muscle mass (a)

Reduced  food intake or assimilation (b)

Inflammation

>5% within past 6 months, or
>10% beyond 6 months

<20 if <70 years, or
<22 if >70 years

Reduced by validated body composition measuring techniquesa

≤50% of ER >1 week, or  any reduction for >2 weeks, or
any chronic GI mal-absorptionb

Acute disease/injuryc or chronic disease-relatedd

Asia:
<18.5 if <70 years, or
<20 if >70 years

 

 

 

 

 

 

 

 

 

 

DISCUSSION: | Back

This GLIM initiative targets the priority to adopt global consensus criteria so that malnutrition prevalence, interventions, and outcomes may be compared throughout the world. A common malnutrition “language” is a paramount necessity in order to support the development of global standards of care that will promote improved outcomes. The proposed approach for diagnosing malnutrition is based upon a strong consensus endorsing core phenotypic and etiologic criteria that are already in widespread use throughout the world. The intent is to promote global use of these criteria that may in turn be readily used with other approaches and additional criteria of regional preference. The consensus criteria are intended to be simple and readily applied by clinicians and other health practitioners using tools and methods that are readily available. Only modest training should be required. The proposed approach encompasses risk screening and diagnosis but does not entail the robust detail of comprehensive nutrition assessment. It will provide a malnutrition diagnosis that may then be complemented by more comprehensive assessments to provide the basis for individualized care and treatment plans. Consultation of skilled nutrition practitioners like dietitians is recommended for severity grading and comprehensive assessment based upon regional preferences and availability. Repeated criterion measures over time are recommended so that trajectories of decline, maintenance, and improvement may be identified.

The recommended GLIM approach encompasses both phenotypic and etiologic criteria. While etiology has not generally been included in criteria supporting the diagnosis of medical conditions in the ICD construct, the inclusion of etiology has been widely adopted in the clinical nutrition community because it serves to guide appropriate interventions and expected outcomes (1). For example, the presence of disease-associated inflammatory response has potential for major impacts upon treatment approach and anticipated outcome. The GLIM approach acknowledges the diversity and the multi-factorial etiologies underlying the development of the malnourished phenotype irrespective of body morphology – lean, normal or obese.

Impairment of muscle strength and function are core phenomena in conditions like sarcopenia (15, 16), cachexia (5, 6), and frailty (20). Assessment of muscle strength should be an integral measure in assessment of patients with suspected sarcopenia since impairment of muscle strength is now recognized as a key component for diagnosis of sarcopenia (15, 16). Though inflammatory mediators and other mechanisms besides malnutrition are at play, it is recommended that the GLIM consensus criteria be applied to diagnose malnutrition in persons with sarcopenia, cachexia, and frailty so that the priority to undertake appropriate nutrition interventions may be recognized. The most helpful approaches for these conditions will however require combined multimodal interventions beyond nutritional supplements, like pharmacological agents and exercise.

Similarly, patients with cachexia will meet GLIM consensus criteria for malnutrition related to chronic disease with inflammation. Since there is concern that inclusion of cachexia with other disease-related malnutrition conditions may diminish appreciation for some distinctive features of cachexia, there has been understandable reluctance by some to equate cachexia with this GLIM diagnosis category. The GLIM consensus criteria for malnutrition are therefore intended to be used in parallel with established concepts and nomenclature, including for example those of cachexia, sarcopenia and frailty.

CONCLUSION: | Back

A strong GLIM consensus endorsed the selected core phenotypic and etiologic criteria that are already in widespread use throughout the world. Many studies provide clear evidence that the agreed upon criteria for diagnosis of malnutrition are highly relevant and each of them alone is able to predict adverse clinical outcomes. Since these criteria may be readily used with other approaches and additional criteria of regional preference, their global adoption is more likely. As the initiative moves forward the creation of databases that use the selected criteria will facilitate the comparison of malnutrition prevalence, interventions, and outcomes throughout the world. Such observations can be used to support the development of global standards of care that will promote improved outcomes.

After the launch of the GLIM consensus it is important that the nutrition community use the criteria both in prospective and retrospective cohort studies as well as clinical trials in order to validate its relevance for clinical practice. Next steps are to secure endorsements from leading nutrition professional societies and to promote dissemination, validation testing, and feedback. The GLIM consensus should be re-evaluated based upon review of new studies and advances in screening and assessment every 3-5 years. We will also seek to share the GLIM consensus recommendations with the World Health Organization in the context of the International Classification of Diseases revision process (ICD-11). This is a high priority since this classification scheme guides clinical diagnosis and reimbursement across much of the world.

REFERENCES: | Back

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Abstract | Introduction | Methodology | Results | Discussion | References | Back to Total Name and Codes page2